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Martin, Ellen 1 . NEW YORK STATE DEPARTMENT OF HEALTH hlif Vital Records Section Burial - Transit ermit Name First Middle Last Sex Ellen Ada Martin Female Date of Death Age If Veteran of U.S. Armed Forces, May 24,2017 78 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death I iv Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation u Medical Certifier Name Title O Jennifer Donovan Address H HN,Johnsburg,NY 12843 Death Certificate Filed District Number �) Register Number X7 City, Town or Village 3 0 Burial Date Cemetery or Crematory May 26,2017 Pine View Crematory Address ©Cremation 21 Quaker Rd., Queensbury, NY 12804 Date Place Removed ZZ I ]Removal and/or Held and/or Address H Hold O Date Point of NTransportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number x° Name of Funeral Home Alexander-Baker Funeral Home 00037 Address 3809 Main Street,Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom 1*-; Remains are Shipped, If Other than Above Address Fte; ILI 12, Permission is hereby granted to dispose of the human remains described above as indicated. u Date Issued 5 j 26 [ 1 7 Registrar of Vital Statistics V" C \ j , (signature) District Number 5 6 0/ Place 6 Fa l S f `?' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z � Date of Disposition Si16I(� Place of Disposition �ne w !'�w;�^� (address) W U) ce (section) f (lot number) (grave number) pName of Sexton or Person in Charge of emises � J-tri.. 5A,44 Z /7 (pl ase print) W Signature v^ Title f6+EiN1 (over) DOH-1555 (02/2004)